Outline

Introduction

Recent advances in postoperative management and stapling devices seem to be improving postoperative clinical course after esophagectomy for esophageal carcinoma. However, cardiopulmonary complications and troubles at the anastomotic site still remains a major problem. Anastomotic stricture still remains one of the major problems after esophagectomy for cancer. We have analyzed factors of anastomotic stricture after esophagectomy for carcinoma, and tried to know the advantages and disadvantages of hand-sewn anastomosis and stapled anastomosis.

Materials and methods

From a series of 46 patients who underwent esophagectomy for esophageal carcinoma, one patient who had necrosis of the gastric conduit after operation was excluded. So the remaining 45 patients were included in the analysis. The mean age was 62.8 years, and the mean follow-up period after operation was 983 days. The type of operation performed was subtotal esophagectomy under right thoracotomy and laparotomy in 35 patients, lower esophagectomy under left thoracotomy and laparotomy in 7 patients, esophagectomy without thoracotomy in 2 patients and laryngopharyngoesophagectomy in one patient.

Results

Overall, 15 of the 45 patients (33%) had anastomotic stricture postoperatively. Anastomotic stricture tended to occur more frequently after subtotal esophagectomy under right thoracotomy and laparotomy (14 out of 35, 40%) than after lower esophagectomy under left thoracotomy and laparotomy (1 out of 7, 14%). There was no significant difference in the frequency of anastomotic stricture between hand-sewn anastomosis (9 out of 29, 31%) and stapled anastomosis (6 out of 16, 38%). Anastomotic stricture occurred 20 to 551 days after operation, and the mean duration after operation was 111.8 days. There was no difference in the duration according to the type of anastomosis. After subtotal esophagectomy, gastric conduit, whole stomach, and colon were used as substitute for esophagus. The frequency of anastomotic stricture was most frequent when colon was used, followed by gastric conduit and whole stomach; however, there was no statistical difference. Of the 15 patients with anastomotic stricture, 6 patients (1 with hand-sewn, and 5 with stapled anastomosis) required dilatation for ten times or less. Nine patients (8 with hand-sewn and 1 with stapled anastomosis) required more than ten times of dilatation procedure, including one patient that required re-anastomosis (patient with stapled anastomosis) and two patients (with hand-sewn anastomosis) still requiring dilatation regularly. Usually the balloon dilatation was performed at 2 atm; however in two patients (one with hand-sewn and one with stapled anastomosis), 5-6 atm of dilatation pressure was required and re-stricture occurred within a couple of weeks after dilatation requiring repeated dilatation. Of the 15 patients with anastomotic stricture, 5 patients (3 of the 9 patients with hand-sewn anastomosis and 2 of the 6 patients with stapled anastomosis) had preceding anastomotic leak. Although there was no statistical difference, patients with anastomotic leak were more liable to develop anastomotic stricture.

Conclusion

Anastomotic stricture after esophagectomy for esophageal cancer tend to occur frequently after subtotal esophagectomy under right thoracotomy and laparotomy, and tend to occur more frequently in patients with stapled anastomosis than in patients with hand-sewn anastomosis. However, anastomotic strictures after stapled anastomosis are usually membranous strictures that could usually be managed by one to six times of endoscopic balloon dilatation. On the other hand, strictures after hand-sewn anastomosis were usually difficult to manage requiring over ten times of repeated balloon dilatation. The results of this study showed the advantages of stapled-anastomosis over hand-sewn anastomosis for reconstruction procedure after subtotal esophagectomy.